Table 2.
Proposed classification of transplant indications for adults—2022.
Disease | Disease status | MSD allo | MUD allo | MMAD allo | Auto | CAR-T |
---|---|---|---|---|---|---|
Haematological malignancies | ||||||
AMLa | CR1 (favourable risk and MRD–)b | GNR/II | GNR/II | GNR/II | CO/I | |
CR1 (favourable risk and MRD+)b | S/II | CO/II | CO/II | GNR/II | ||
CR1 (intermediate risk)b | S/II | CO/II | CO/II | CO/I | ||
CR1 (adverse risk)b | S/II | S/II | S/II | GNR/I | ||
CR2 | S/II | S/II | S/II | CO/II | ||
APL Molecular CR2 | S/II | CO/II | GNR/III | S/II | ||
Relapse or refractory | CO/II | CO/II | CO/II | GNR/III | ||
ALLa | Ph (–), CR1 (standard risk and MRD–)b | GNR/II | GNR/II | GNR/III | CO/III | |
Ph (–), CR1 (standard risk and MRD+)b | S/II | CO/II | CO/II | GNR/II | CO/II | |
Ph (–), CR1 (high risk)b | S/II | S/II | CO/II | GNR/III | ||
Ph (+), CR1 (MRD–) | S/II | S/II | CO/II | CO/III | ||
Ph (+), CR1 (MRD+) | S/II | S/II | S/II | GNR/II | ||
CR2 | S/II | S/II | S/II | GNR/II | ||
Relapse or refractory | CO/II | CO/II | CO/II | GNR/III | ||
CML | 1st CP, failing 2nd or 3rd line TKI | S/II | S/II | CO/III | GNR/II | |
Accelerated phase, blast crisis or >1st CP | S/II | S/II | CO/II | GNR/III | ||
Myelofibrosis | Primary or secondary with an intermediate-2 or high DIPSS score | S/II | S/II | S/III | GNR/III | |
MDS | Very low and low-risk (IPSS-R) | CO/II | CO/II | CO/II | GNR/III | |
Intermediate-risk without additional factorsc (IPSS-R) | CO/II | CO/II | CO/II | CO/II | ||
Intermediate-risk with additional factorsc (IPSS-R) | S/II | S/II | S/II | GNR/III | ||
High-, very high-risk (IPSS-R) | S/II | S/II | S/II | |||
sAML in CR1 or CR2 | S/II | S/II | ||||
CMML | CMML-2 or MP-CMML | S/II | S/II | S/II | GNR/III | |
CMML-0 or CMML-1 with additional risk factorsd | S/II | S/II | S/II | GNR/III | ||
CLL | Poor risk disease refractory or relapsing after at one line of prior therapy (Richter’s transformation excluded) | CO/II | CO/II | GNR/III | GNR/III | CO/II |
Richter transformation | S/II | S/II | S/II | GNR/III | CO/II | |
LBCL | CR1 (intermediate/high IPI at diagnosis) | GNR/III | GNR/III | GNR/III | CO/I | GNR/III |
Untested relapse | GNR | GNR | GNR | GNR | S/I | |
Chemosensitive early relapse, ≥CR2 | CO/II | CO/II | D/III | CO/I | S/II | |
Chemosensitive late relapse, ≥CR2 | CO/II | CO/II | D/III | S/II | CO/II | |
Chemosensitive relapse after auto-HSCT failure | CO/II | CO/II | CO/III | GNR/III | S/II | |
Refractory disease | CO/II | CO/II | CO/III | GNR/I | S/I | |
Primary CNS lymphoma | GNR/III | GNR/III | GNR/III | S/II | D/III | |
FL | CR1, untransformed | GNR/III | GNR/III | GNR/III | GNR/II | GNR/III |
CR1, transformed into high-grade lymphoma | GNR/III | GNR/III | GNR/III | CO/III | GNR/II | |
Chemosensitive relapse, ≥CR2 | CO/III | CO/III | GNR/III | S/II | GNR/III | |
≥CR2 after auto-HSCT failure | S/II | S/II | D/III | GNR/III | CO/II | |
Refractory | CO/II | CO/II | CO/III | GNR/III | CO/II | |
MCL | CR1 | GNR/III | GNR/III | GNR/III | S/I | GNR/III |
CR/PR >1, no prior auto-HCT | CO/III | CO/III | D/III | CO/II | S/II | |
CR/PR >1, after prior auto-HCT | CO/II | CO/II | CO/III | GNR/II | S/II | |
Refractory | CO/II | CO/II | CO/III | GNR/II | S/II | |
WM | CR1 | GNR/III | GNR/III | GNR/III | GNR/III | GNR/III |
Chemosensitive relapse, ≥CR2 | GNR/III | GNR/III | GNR/III | CO/II | GNR/III | |
Poor risk disease | CO/II | CO/II | D/III | GNR/III | GNR/III | |
PTCL | CR1 | CO/II | CO/II | GNR/III | CO/II | GNR/III |
Chemosensitive relapse, ≥CR2 | S/II | S/II | CO/III | CO/II | GNR/III | |
Refractory | CO/II | CO/II | CO/III | GNR/II | GNR/III | |
Primary CTCL | EORTC/ISCL Stages I–IIA (early) | GNR/III | GNR/III | GNR/III | GNR/III | GNR/III |
EORTC/ISCL Stages IIB–IV (advanced) | CO/III | CO/III | D/III | GNR/III | GNR/III | |
HL | CR1 | GNR/III | GNR/III | GNR/III | GNR/I | GNR/III |
Chemosensitive relapse, no prior auto-HCT | D/III | D/III | GNR/III | S/I | GNR/III | |
Chemosensitive relapse, after prior auto-HCT | S//II | S/II | S/II | CO/III | GNR/III | |
Refractory | D/II | D/II | D/III | CO/III | GNR/III | |
MM | Upfront standard risk | CO/II | CO/II | GNR/III | S/I | |
Upfront high risk | S/III | S/III | CO/II | S/I | ||
Chemosensitive relapse, prior auto-HCT | CO/II | CO/II | CO/II | S/II | GNR/III | |
Refractory/relapse after three lines of prior therapy including an immunomodulatory agent, a proteasome inhibitor and an anti-CD38 | S/II | |||||
AL | CO/III | CO/III | GNR/III | CO/II | ||
Other diseases | ||||||
Acquired SAA and AA/PNH | Newly diagnosed | S/II | CO/II | GNR/III | NA | |
Relapsed/refractory | S/II | S/II | CO/II | NA | ||
Haemolytic PNH | GNR/II | GNR/II | GNR/II | NA | ||
Constitutional BMF syndromes/SAAe | S/II | S/II | CO/II | NA | ||
Breast Ca | Adjuvant high risk, selected population | NA | NA | NA | D/CO/I | |
Metastatic, chemosensitive | D/II | NA | NA | D/CO/II | ||
Germ cell tumours | Second line, high risk | GNR/III | NA | NA | CO/II | |
Primary refractory, second and further relapse | GNR/III | NA | NA | S/II | ||
Ovarian Ca | High risk/recurrent | GNR/II | NA | NA | GNR/I | |
Medulloblastoma | Post-surgery, high risk/recurrent disease | NA | NA | NA | CO/III | |
Small cell lung Ca | Limited | NA | NA | NA | GNR/I | |
Soft tissue Sa | Advanced | D/III | NA | NA | D/II | |
Ewing’s Sa | Locally advanced/metastatic, chemosensitive | D/III | NA | NA | CO/II | |
Renal cell Ca | Metastatic, refractory to conventional treatments | D/II | NA | NA | NA | |
Colorectal Ca, pancreatic Ca, other selected solid tumours | Metastatic, refractory to conventional treatments | D/III | NA | NA | NA | |
Multiple sclerosis | Highly active RR-MS failing DMT | D/III | GNR/III | GNR/III | S/I | |
Progressive MS with AIC, and Aggressive MSf | D/III | GNR/III | GNR/III | CO/II | ||
Progressive MS without AIC | GNR/III | GNR/III | GNR/III | GNR/III | ||
Systemic sclerosis | D/III | GNR/III | GNR/III | S/I | ||
SLE | D/III | GNR/III | GNR/III | CO/II | ||
Crohn’s disease | D/III | D/III | D/III | CO/II | ||
Rheumatoid arthritis | D/III | GNR/III | GNR/III | CO/II | ||
JIA | CO/II | CO/II | CO/III | CO/II | ||
Monogenic AD | CO/II | CO/II | CO/III | GNR/II | ||
Vasculitis | ANCA+ve, BD, Takayasu, others | GNR/III | GNR/III | GNR/III | CO/II | |
PM-DM | GNR/III | GNR/III | GNR/III | CO/II | ||
Autoimmune cytopenias | CO/II | CO/II | CO/III | CO/II | ||
Neuromyelitis optica | D/III | D/III | D/III | CO/II | ||
CIDP, MG and SPS | GNR/III | GNR/III | GNR/III | CO/II | ||
Type 1 diabetes | GNR/III | GNR/III | GNR/III | D/II | ||
RCD type II | GNR/III | GNR/III | GNR/III | CO/II | ||
Primary ID | CO/II | CO/II | CO/II | NA |
This classification does not cover patients for whom a syngeneic donor is available.
AA aplastic anaemia, AD autoimmune disorders, AIC active inflammatory component, AL amyloidosis, ALL acute lymphoblastic leukaemia, Allo allogeneic transplantation, AML acute myeloid leukaemia, APL acute promyelocytic leukaemia, Auto autologous transplantation, Ca cancer or carcinoma, CAR-T chimeric antigen receptor T cells, CIDP chronic inflammatory demyelinating polyneuropathy, CLL chronic lymphocytic leukaemia, CML chronic myelogenous leukaemia, CMML chronic myelomonocytic leukaemia, CO clinical option (can be carried after careful assessment of risks and benefits), CP chronic phase, CR1, 2, 3 first, second, third complete remission, CTCL cutaneous T-cell lymphoma, D developmental (further trials are needed), DIPSS dynamic international prognostic score system, DMT disease-modifying treatments, FL follicular lymphoma, GNR generally not recommended, HL Hodgkin lymphoma, HCT haematopoietic cell transplantation, ID immunodeficiency, IPI international prognostic index, IPSS-R revised International Scoring System, JIA juvenile idiopathic arthritis, LBCL large B-cell lymphoma, MCL mantle cell lymphoma, MDS myelodysplastic syndromes, MG myasthenia gravis, MM multiple myeloma, MMAD mismatched alternative donors (cord blood, haploidentical and mismatched unrelated donors), MP-CMML myeloproliferative CMML, MRD minimal residual disease, MS multiple sclerosis, MSD matched sibling donor, MUD well-matched unrelated donor (8/8, 10/10, or 9/10 if mismatched is in DQB1), NA not applicable, PM-DM polymyositis-dermatomyositis, PNH paroxysmal nocturnal haemoglobinuria, PR partial remission, RA refractory anaemia, RAEB refractory anaemia with excess blasts, RCD refractory coeliac disease, RCMD refractory cytopenia with multilineage dysplasia, RR-MS relapsing-remitting multiple sclerosis, S standard of care (generally indicated in suitable patients), Sa sarcoma, SAA severe aplastic anaemia, sAML secondary acute myeloid leukaemia, SLE systemic lupus erythematosus, SPS stiff person syndrome, TCL T-cell lymphoma, TKI tyrosine kinase inhibitors, WM Waldenström macroglobulinemia.
aSome centres consider older age (e.g., >60 years) as a criterion for high-risk disease in decision making for allogeneic HSCT for AML or ALL. Beyond transplant indications, maintenance therapy after transplant is being increasingly used with the aim of improving survival outcomes (e.g., FLT3 inhibitors in FLT3-ITD AML [346]).
bCategories are based on number of white blood cells, cytogenetics and molecular markers at diagnosis and time to achieve remission (see text).
cAdditional factors include >5% marrow blasts, poor karyotype, profound cytopenias (i.e., Hb <80 g/L, ANC <0.8 × 109/L, platelets <50 × 109/L), or severe BM fibrosis.
dAdditional high-risk gene mutations (ASXL1, RUNX1, SETBP1, N-RAS), severe cytopenia or transfusion dependency, excessive proliferative features or extramedullary involvement.
eConstitutional SAA includes Fanconi anaemia, dyskeratosis congenita, Blackfan–Diamond anaemia and other inborn bone marrow failure syndromes (see also the section and table for paediatric indications).
fAggressive MS as per Menon et al. [347].